Provider Demographics
NPI:1205850013
Name:ROSE, GARY S (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:ROSE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 COACHMEN LN
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-2027
Mailing Address - Country:US
Mailing Address - Phone:978-250-8400
Mailing Address - Fax:
Practice Address - Street 1:229 BILLERICA RD
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-3603
Practice Address - Country:US
Practice Address - Phone:978-250-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3515103TC0700X
ME839103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03656Medicare ID - Type Unspecified